Expert-generated standard practice elements for evidence-based home visiting programs using a Delphi process

Background States, territories, non-profits, and tribes are eligible to obtain federal funding to implement federally endorsed evidence-based home visiting programs. This represents a massive success in translational science, with $400 million a year allocated to these implementation efforts. This legislation also requires that 3% of this annual funding be allocated to tribal entities implementing home visiting in their communities. However, implementing stakeholders face challenges with selecting which program is best for their desired outcomes and context. Moreover, recent reviews have indicated that when implemented in practice and delivered at scale, many evidence-based home visiting programs fail to replicate the retention rates and effects achieved during clinical trials. To inform program implementers and better identify the active ingredients in home visiting programs that drive significant impacts, we aimed to develop an expert derived consensus taxonomy on the elements used in home visiting practice that are essential to priority outcome domains. Methods We convened a panel of 16 experts representing researchers, model representatives, and program implementers using a Delphi approach. We first elicited standard practice elements (SPEs) using open-ended inquiry, then compared these elements to behavior change techniques (BCTs) given their general importance in the field of home visiting; and finally rated their importance to 10 outcome domains. Results Our process identified 48 SPEs derived from the panel, with 83 additional BCTs added based on the literature. Six SPEs, mostly related to home visitor characteristics and skills, were rated essential across all outcome domains. Fifty-three of the 83 BCTs were rated unnecessary across all outcome domains. Conclusions This work represents the first step in a consensus-grounded taxonomy of techniques and strategies necessary for home visiting programs and provides a framework for future hypothesis testing and replication studies.

EBHV, including buy-in (community, agency, home visitor), staff training, supervision, fidelity, funding, and payment structures. Example: Program leadership; Developing content mastery and delivery skills for home visitors, recruitment and retention of home visitors, training, and supervision; Fidelity assessment

Home visiting content elements
The content (i.e. the "what") that is conveyed by home visitors to their clients during service delivery. Example: Home visitors engaging in information sharing for their clients to cover a broad range of topics (e.g. child development, pregnancy, labor and delivery, breastfeeding)

Home visiting process/ delivery elements
The strategies and techniques home visitors use during service delivery with their clients.
Example: Home visitor and client role play, skills practice, test taking, recitation, videos and discussion

Home visitor personal characteristics
Home visitor characteristics that may contribute to improvement in client outcomes but that aren't typically specified in a model's theoretical/ conceptual framework or their content. These are aspects of the home visitor that are not an explicit part of the model. Example: Home visitor flexibility and adaptability, cultural humility, maturity, patience The following elements fall under the macro element called information sharing (by home visitor to client). Please select which broad category each falls into. Check all that apply.
Information sharing (broadly) Model  Information sharing (maternal and child health) Information sharing (discipline and behavior management) Teaching about family relationships and co-parenting

Model philosophy elements
The tenets of an EBHV that drive the other components of home visiting, including a model's theory of change and cultural lifeways.
Example: we believe parents should be a child's first and best teacher; thus, our theory of change involves home visitors teaching parents who teach their children

Program implementation elements
Strategies, techniques, structures, and processes (e.g. program design) at the model/organizational/site level that relate to ensuring successful delivery of the Example: Home visitors engaging in information sharing for their clients to cover a broad range of topics (e.g. child development, pregnancy, labor and delivery, breastfeeding)

Home visiting process/ delivery elements
The strategies and techniques home visitors use during service delivery with their clients. Example: Home visitor and client role play, skills practice, test taking, recitation, videos and discussion

Home visitor personal characteristics
Home visitor characteristics that may contribute to improvement in client outcomes but that aren't typically specified in a model's theoretical/ conceptual framework or their content. These are aspects of the home visitor that are not an explicit part of the model. Example: Home visitor flexibility and adaptability, cultural humility, maturity, patience The following elements fall under the macro element called staffing/ Proper workloads of staff/supervisors

Model philosophy elements
The tenets of an EBHV that drive the other components of home visiting, including a model's theory of change and cultural lifeways.
Example: we believe parents should be a child's first and best teacher; thus, our theory of change involves home visitors teaching parents who teach their children

Program implementation elements
Strategies, techniques, structures, and processes (e.g. program design) at the model/organizational/site level that relate to ensuring successful delivery of the EBHV, including buy-in (community, agency, home visitor), staff training, supervision, fidelity, funding, and payment structures. Example: Program leadership; Developing content mastery and delivery skills for home visitors, recruitment and retention of home visitors, training, and supervision; Fidelity assessment

Home visiting content elements
The content (i.e. the "what") that is conveyed by home visitors to their clients during service delivery. Example: Home visitors engaging in information sharing for their clients to cover a broad range of topics (e.g. child development, pregnancy, labor and delivery, breastfeeding)

Home visiting process/ delivery elements
The strategies and techniques home visitors use during service delivery with their clients.

Home visiting content elements
The content (i.e. the "what") that is conveyed by home visitors to their clients during service delivery.
Example: Home visitors engaging in information sharing for their clients to cover a broad range of topics (e.g. child development, pregnancy, labor and delivery, breastfeeding)

Home visiting process/ delivery elements
The strategies and techniques home visitors use during service delivery with their clients. Example: Home visitor and client role play, skills practice, test taking, recitation, videos and discussion

Home visitor personal characteristics
Home visitor characteristics that may contribute to improvement in client outcomes but that aren't typically specified in a model's theoretical/ conceptual framework or their content. These are aspects of the home visitor that are not an explicit part of the model.
Example: Home visitor flexibility and adaptability, cultural humility, maturity, patience Which broad category does model is based on a parenting framework fall into? Check all that apply.
Which broad category does teaching coping skills to parents fall into?
Check all that apply.
Which broad category does program is data driven fall into? Check all that apply.
Which broad category does recruitment of/ outreach to parents fall into?
Check all that apply. Are there any additional elements you would like to add?
Name of the person who filled out this questionnaire Thank you for taking the time to complete Questionnaire #2 for the EBHV standard practice elements project. We will combine data and follow-up to schedule the next video conference.